Helmets reduced the risk and severity of head and neck injuries without increasing risky behavior in skiers and snowboarders, researchers found.

Action Points

This evidence-based review found that safety helmets clearly decrease the risk and severity of head injuries in skiing and snowboarding.

The review also found that the use of helmets did not increase the risk of neck injury or risk compensation behavior.

Helmets reduced the risk and severity of head and neck injuries without increasing risky behavior in skiers and snowboarders, researchers found.

A systematic review of literature related to head, neck, and cervical spine injuries in skiers and snowboarders showed helmet use did not increase the prevalence of riskier behavior, while offering a protective effect against head, neck, or cervical spine injury, according to Adil Haider, MD, and colleagues, on behalf of the Eastern Association for the Surgery of Trauma Injury Control/Violence Prevention Committee.

Skiers and snowboarders should wear helmets to reduce incidence and severity of injuries, the researchers wrote online in The Journal of Trauma and Acute Care Surgery.

No prior recommendations had been made before the review due to reports "about the possible increase in risk compensation behavior and neck injuries associated with helmet use during skiing and snowboarding," the authors noted.

They added that "injuries sustained during recreational skiing and snowboarding can cause significant morbidity and mortality among snow sport enthusiasts," including traumatic head injury, hospitalization, fatality, and long-term disability.

The researchers analyzed 16 studies that provided data on any of three primary endpoints:

Helmet use in association with fatal and nonfatal head injury

Helmet use in association with neck and cervical spine injury

Helmet use in association with risk compensation

Among studies with data on head injuries, one Canadian study found an overall reduced odds of any head injury with helmet use (OR 0.71, 95% CI 0.55 to 0.92), and 56% reduced odds of severe head wounds (95% CI 0.24 to 0.81).

A second Canadian study showed children who did not wear helmets had greater than twice the increased odds of neck, head, or face injuries on the slopes (RR 2.24, 95% CI 1.23 to 4.12).

Data from studies looking at neck and cervical spine injury rates showed wearing a helmet did not increase risks of injury overall.

Rates of any injury (aOR 1.09, 95% CI 0.95 to 1.25), isolated ambulance-evacuated neck injury (aOR 1.28, 95% CI 0.96 to 1.71), and cervical spine fracture and dislocation (aOR 1.02, 95% CI 0.79 to 1.31) were not statistically increased in patients who wore a helmet, according to one Canadian study.

An additional two case-control studies also found a lack of increased risk of neck injury among patients wearing helmets. A third case-control study showed a nonsignificant two-fold increased risk of neck injury among patients who did not wear helmets, but the study's sample size was too small to achieve any statistical power (P=0.15).

In their analysis of risky behavior, the authors noted that risk compensation occurs in patients who dial up their "risk thermostat" when there is a perception of reduced risks through another intervention, such as helmet use.

However, they found that there was no association between increased risky behavior among skiers and snowboarders who wore helmets when compared with those who did not.

The authors cited a retrospective case series that showed with nearly four-fold increased odds that "helmet use was more likely in those who thought that helmets reduce their chance of severe injury" (OR 3.6, 95% CI 2.1 to 6.4) and with nearly five-fold increased odds that it was more likely "among those who thought that helmet use should be mandatory" (OR 4.8, 95% CI 2.7 to 8.5).

"The beneficial effects of helmets are not negated by unintended risks because their use does not seem to increase the risk of neck or cervical spine injury as compared with non-helmeted participants in skiing and snowboarding," they concluded.

The authors noted a number of limitations with their review, including a lack of randomized controlled trials; less controllable factors such as participant skill and slope conditions; variable definitions of head, neck, and cervical spine injury; bias due to temporal study proximity to high-profile celebrity deaths; and the overall small sample size of fatalities among the studies.

The study was funded by grants from the National Institutes of Health and the American College of Surgeons' C. James Carrico Fellowship for the Study of Trauma and Critical Care.

The authors declared no conflicts of interest.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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